Formulir Pendaftaran Anggota HPCI
HondaPCX Club Indonesia
DATA PRIBADI
PERSONAL PARTICULARS
Nama Lengkap *
Full Name
Your answer
Jenis Kelamin *
Tempat Lahir *
Place of birth
Your answer
Tanggal Lahir *
MM
/
DD
/
YYYY
Alamat *
Address
Your answer
Telepon Selular *
Mobil Phone
Your answer
Telepon Darurat
Emergency Number
Your answer
Email *
Email Address
Your answer
Jenis Identitas *
Type of Identity
Nomor Identitas *
Identity No
Your answer
Agama *
Religion
Golongan Darah *
Blood type
Your answer
DATA KENDARAAN
VIHICLES INFORMATION
Nomor Polisi *
License Plate
Your answer
Warna Motor *
Color Of PCX
Your answer
Nomor STNK *
No. Reg STNK
Your answer
Tahun Pembuatan *
Year Manufacture
Your answer
No. Rangka *
Chassis Number
Your answer
No. Mesin *
Marchine Number
Your answer
Catatan
Pertanyaan Kritik & Saran
Your answer
Pernyataan *
Required
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